For babies in the NICU, learning to breastfeed or bottlefeed is a major task and learning experience. It can feel like a rollercoaster. Highs and lows. One step forward, two steps back. There are things you can do to help set your baby up for success early on.

It may seem like your baby’s feeding journey begins once they’re taking a bottle or go to the breast for the first time. 

In reality, your baby’s feeding journey begins at birth.

Actually, before your baby was even born, they were learning to taste and swallow amniotic fluid. They have been working on those oral skills for a while.

Sometimes, babies can develop what we call “oral aversion”, which means they avoid and perceive input around their mouth (or even face) as negative. 

Babies can also struggle with handling and sensory input in general. In the NICU world those babies are sometimes called “touch-me-nots”.

Supporting oral experiences will support your baby’s entire sensory system, including touch. Here are some other ways you can support “touch-me-not” babies in the NICU. 

SIGNS OF ORAL AVERSION

Oral aversion can be recognized by watching the behaviors that occur following introduction of oral input, like a bottle nipple, pacifier, or the breast. When looking for signs of oral aversion, look for multiple signs. These behaviors can be indicative of other things as well. Some of these signs are

• Turning away 
• Gagging
• Facial grimacing
• Furrowing brows 
• Arching
• Pursed (tightly closed) lips

Not only can this create a major speed bump in the feeding process, but it can impact their long-term feeding journey.

Since preventing oral aversion and negative oral experiences starts at birth, let’s talk about 9 simple changes you can make during care to promote positive oral experiences and set a strong foundation for early feeding success.

1. Prioritize positive oral experiences early on.

Like I mentioned above, feeding success doesn’t start once your baby starts breastfeeding or bottle feeding. It starts at birth.

Babies in the NICU often receive a lot of procedure-based and negative input around their mouth and face.

Some examples of procedure-based touch or negative oral experiences include:

• Presence of a breathing tube, or an orogastric (OG) tube.
• Tape being placed and removed from their lip and face.
• Oral suctioning
• Intubation (placement of a breathing tube)
• Reflux

The strategies in this post can be used to prioritize positive oral experiences and support self-regulation in the NICU.

2. Before oral care or handling, provide comforting interventions.

To prevent oral aversion, we want to decrease the number of negative experiences your baby has. And that extends beyond oral experiences.

Before you head in to interact with your baby and do your assessment…

1. first, talk quietly to your baby, 
2. then place your warm hands on their body and give them a hand hug. 

Babies in the NICU are smart. Watch for your baby’s cues. 

They’ll let you know if they’re feeling stressed or overstimulated. 

Once you’ve introduced them to some gentle input…their body and brain is more regulated and ready for what’s to come.

Like suctioning their breathing tube, or providing oral care. 

By focusing on supporting the sensory experiences of the whole baby, we’re supporting feeding success and the development of coping skills early on.

3. Use breastmilk during oral care.

Oral care is when you clean off the inside of your baby’s mouth, around their breathing tube (if they have one), or wipe off their lips.

Most often your baby will receive oral care using a sterile water solution.

Instead of using sterile water, if your baby tends to show stress responses during their oral care, you can use breastmilk instead. 

Breastmilk is naturally sweet, and it offers a comforting effect for babies.

You only need the tiniest bit, just a drop or two, and that’s it.

Pumping breast milk for your baby is an amazing, developmentally-supportive activity you can do even when you’re unable to be at your baby’s bedside.

4. Use a gauze pad to wipe mouth gently.

There can be a lot of slobbery little babes in the NICU. 

Sometimes they even blow bubbles (and it’s adorable!).

Your baby’s secretions can pool around their cheeks, lips and mouth. Many times we clear secretions by using a small oral suction catheter.

It’s typically hooked up to the wall, and you stick the tip into the baby’s cheek so it can suction out all the secretions (kind of like when you’re at the dentist). 

Sometimes they use a bulb syringe.

Take note of how your baby’s secretions are being managed. 

If the secretions are outside of your baby’s mouth, and are NOT impacting their comfort or medical stability…wipe them away gently using a small gauze pad.

Using a soft, small gauze pad will be a more positive sensory experience for your baby, but you’ll still be able to keep their mouth clean and dry.

5. Avoid over-suctioning the oral cavity unless medically necessary.

There can be a strong desire to suction out secretions whenever we see them. I want to encourage us not to jump at every bubble or drop of drool.

If your baby appears comfortable, is medically stable, and the secretions are not impacting the integrity of the tape on their face (and they have received adequate oral care), leave it be.

If your baby needs it, of course…suctioning is a VERY IMPORTANT medical tool to be used when medically indicated.

It is an important tool to prevent pneumonia.

The best way to create positive experiences in the NICU and support feeding success, is by decreasing the number of times we do negative things around the baby’s mouth.

6. Focus on baby-driven feeding, not volume-driven.

There are several different ways to approach feeding a baby in the NICU. 

Volume-driven feeding places a heavy focus on the AMOUNT your baby has taken. 

Baby-driven feeding focuses more on responding to a baby’s cues, even if they didn’t take their full volume.

Using a baby-driven feeding method prevents pushing babies to take more food than they want and focuses on creating positive feeding experiences.

7. Allow baby to lick and nuzzle at the breast prior to initiating oral feeding.

There are a lot of different ways to introduce breast-feeding in the NICU. 

If a mom is interested in breast-feeding, it can be beneficial to place a baby skin-to-skin, and allow them to migrate to mom‘s breast to lick and nuzzle.

The focus is not for a baby to latch and extract milk from the nipple.

The purpose is to create positive sensory experiences and neurologic pathways.

This can start weeks before a baby starts taking bottles or breastfeeding.

8. Focus on skin-to-skin holding, early and often.

Skin-to-skin is when your baby is placed on mom’s chest skin-to-skin for holding, also called “kangaroo care”. There are SO many incredible developmental and medical benefits to holding skin-to-skin in the NICU.

This strategy can begin long before a baby starts to take bottles or breastfeed.

Once your baby is medically stable, and able to tolerate the transition out of bed for holding…hold your baby skin-to-skin as much as possible.

Some benefits of kangaroo care include:

• better sleep cycles,
• improved weight gain,
• more stable heart rate and oxygen rates,
• improved parent confidence,
• and more positive maternal mental health outcomes.

There may be moments in the NICU journey when babies have a difficult time tolerating skin-to-skin care. It’s not because of you!

If your baby struggles with skin-to-skin holding, here are 7 possible reasons why.

9. Offer your baby a pacifier.

Pacifiers can be a hot topic in the baby world. Let me tell you why it can be beneficial to introduce your premature baby to the pacifier while they’re in the NICU. 

Pacifiers are one of the most effective stress prevention interventions available, which means your baby is building stronger coping skills, improved self-regulation, and positive oral experiences.

Plus, they’re practicing sucking and breathing at the same time.

Learning to eat by mouth by bottlefeeding or breastfeeding is a major accomplishment (and journey!) for babies and families in the NICU.

Try using some of these strategies with your baby and help create positive oral experiences that set them up for success.

Did your baby experience an oral aversion? What strategies helped them succeed?